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European Resuscitation Council
Objectives
 To know basic elements to evaluate patients
with rythm disturbance
 To know advanced treatment of paediatric
cardiac arrest
 To know emergency treatment of most
frequent pediatric disrrhythmias
General Considerations
 In children arrhythmias are more often the
consequence of hypoxaemia, acidosis and
hypotension
 Primary cardiac diseases are rare
 Monitoring cardiac rythm is mandatory in
advanced life support to evaluate cardiac
function and response to therapy
Three Classes of Rhythm Disturbances
Absent pulse – cardiac arrest rhythms
Slow pulse – bradyarrhythmias
Fast pulse - tachyarrhythmias
Factors Involved
 Careful evaluation of patient clinical status
ABC !!!
 Rapid evaluation of the rhythm on the monitor
First law:
“Treat the patient not the monitor”
Useful Questions for a Child With Arrhythmia
Is the pulse present ?
Is the child in shock ?
Is the heart rate fast or slow ?
Is the rhythm regular or irregular ?
Are QRS complexes narrow or wide ?
Cardiac Rate
Age
Tachycardia
Bradycardia
<1y
>1y
> 180 bpm
>160 bpm
< 80 bpm
< 60 bpm
QRS (0.08 sec)
0,20
sec
0,04 sec
ECG
Narrow QRS
Wide QRS
Cardiac Arrest
ABC
Check the pulse
Attach monitor/defibrillator
NON VF/ VT
VF/ VT
Asystole / Pulseless
Electrical Activity (PEA)
Ventricular Fibrillation (VF)
Ventricular Tachycardia (VT)
Cardiac arrest rhythms
Asystole
80%
PEA
14%
FV/TV
6%
Magyzel - 1995
VF 0-8 y
3%
VF 8-30 y
17%
Appleton - 1995
No Pulse
Non – VF/ VT
Asystole
No Pulse
Non – VF/ VT
Pulseless Electrical Activity
(PEA)
Evaluate Rhythm
Non VF/ VT
CPR
Adrenaline
CPR 3’
Adrenaline
 I.V / I.O
0.1 ml/kg
10 mcg /kg
of 1:10 000 solution
 E.T
0.1ml/kg
100 mcg/kg
of
1:1 000 solution
 May be repeated every 3-5 minuts
No Pulse
VF/VT
Ventricular Fibrillation
No Pulse
VF/VT
Ventricular Tachycardia
Evaluate Rhythm
VF/VT
Defibrillate
1st : 2 J/Kg - 2 J/Kg - 4 J/Kg
2nd : 4 J/Kg - 4 J/Kg - 4 J/Kg
Adrenaline
•After 1st 3 shocks
•Repeat every 3 min.
CPR
1 minute
Other drugs
Drugs
•Amiodarone
5 mg/Kg I.V /I.O in bolus
•Lidocaine
1 mg/Kg I.V /I.O in bolus
•Magnesium sulfate
25-50 mg/Kg I.V /I.O (max 2gr)
Indication: torsades de pointe, hypomagnaesiemia
•Sodium Bicarbonate
1mEq/Kg I.V /I.O
Absent Pulse
CPR
Attach defibrillator/monitor
Rhythm ?
VF/VT
CPR
Defibrillate
Up to 3 shocks
During CPR
Drugs
CPR
1 minute
Reassess
Non VF/VT
Adrenaline
CPR
3 minutes
Reassess
During CPR






Attempt /Verify
Tracheal intubation
Intraosseus /Vascular access
Electrodes/Paddles position and contact
Adrenaline every 3 minutes
Check
Give
Consider antiarrhythmics
Consider acidosis
Consider giving Bicarbonate
Correct reversible causes ( 4H/4T)
Hypoxia
Hypovolaemia
Hyper/hypokalaemia
Hypothermia
Tension Pneumothorax
Tamponade
Toxic/therapeutic medic
Thromboemboli
Slow Pulse
Bradycardia
Slow Pulse - Bradyarrythmias
 Most frequent pre-terminal rhythm in the
critically ill child
 In paediatric age, most frequently caused by
hypoxia, acidosis, hypotension, hypothermia
and hypoglycaemia, rather than of primary
cardiac origin
 Increased vagal tone and CNS insults also
may lead bradycardia
Bradycardia <60 bpm
Oxygenate/ventilate
Poor perfusion ?
During CPR
•Intubation
•Vascular Access IO/IV
Chest Compression
•Treat possible causes
•Consider continuous infusion
adrenaline/dopamine
•Consider cardiac pacing
Adrenaline
Atropine
1st choice if vagal tone or AV block
reassess
Drugs for Bradycardia
Oxygen !!!!!!
Adrenaline
 I.V/ I.O
 E.T
10 mcg/kg (1:10000 , 0.1 ml/kg)
100 mcg/kg (1:1000, 0.1ml/kg)
Atropine
 I. V
0.02 mg/kg
 Minimum dose :
0.1 mg
 Max single dose :
0.5 mg child
1 mg adolescent


Can be repeated 1 time after 5 min.
Max dose
1 - 2 mg c / a
Fast Pulse - Tachyarrhythmias
Assess ABC
Shock ?
QRS duration
Narrow QRS
Sinusal Tachycardia
Supraventricular Tachycardia
Wide QRS
Ventricular Tachycardia
Fast Pulse - Narrow QRS
Sinusal tachycardia
Fast Pulse - Narrow QRS
Supraventricular Tachycardia
Fast Pulse
Narrow QRS
Probable TS




P present and normal
Variable RR
< 1 y HR < 220 bpm
> 1 y HR < 180 bpm
Probable TSV




P absent or abnormal
Fixed RR
< 1 y HR > 220 bpm
> 1 y HR > 180 bpm
TACHYARRYTHMIA
ABC
See CRA algorithm
QRS  0.08 sec
NO
Palpable pulse?
YES
QRS > 0.08 sec
QRS duration?
Evaluate rhythm
Probable sinus
tachycardia *
Probable supraventricular
tachycardia *
Probable ventricular
tachycardia *
Urgent vagal manœuvres
No delay
*Consider reversible causes
Hypoxemia
Hypovolaemia
Hyperthermia
Hyper/hypokaliemia
Tamponade
Tension Pneumothorax
Toxics / Medications
Thrombo-embolism
Pain
Immediate Cardioversion
Or
Immediate Adenosine*
Consider other medications
*if IV access immediately
available
Consult Paediatric
Cardiologist
Vagal Manoeuvres
Diving reflex
Valsalva maneuver
Carotid sinus massage
Adenosine
 Action
block AV node
 Half-life 10 sec
 Time of action < 2 min
 Dose 0.1 mg/Kg (max 1st dose 6 mg)
then 0.2 mg/Kg (max 2nd dose 12 mg)
Fast Bolus I.V/I.O
+ flush 3-5ml NS
Synchronized Cardioversion
1st dose 1 J/Kg
if necessary up to 2 J/Kg
Fast Pulse - Wide QRS
Ventricular tachycardia
PROBABLE VENTRICULAR TACHYCARDIA
See CRA algorithm
NO
Palpable pulse?
YES
NO
Poor perfusion
Consult pediatric cardiologist
Cardioversion with sedation
0.5 to 1 J/kg
Immediate Cardioversion
0.5 – 1 J/kg
Sedation if possible
Consider other medications
*Consider reversible causes
Hypoxemia
Hypovolaemia
Hyperthermia
Hyper/hypokaliemia
Tamponade
Tension Pneumothorax
Toxics / Medications
Thrombo-embolism
Pain
YES
Amiodarone 5 mg/kg IV in 20-60 min
Procaïnamide 15 mg/kg IV in 30-60 min
Lidocaïne 1 mg/kg IV bolus
Don’t associate Amiodarone and
Procaïnamide
Conclusions
We discuss about…
• basic elements to evaluate patients with
rhythm disturbance
• advanced treatment of paediatric cardiac
arrest
• emergency treatment of most frequent
paediatric disrhythmias